Deficiencies (last 3 years)
Deficiencies (over 3 years)
21 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
347% worse than Pennsylvania average
Pennsylvania average: 4.7 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Complaint Investigation
Deficiencies: 13
Date: Mar 24, 2025
Visit Reason
The inspection was conducted based on complaints and concerns related to resident care, safety, abuse, medication administration, grievance handling, and facility conditions.
Complaint Details
The complaint investigation revealed multiple issues including medication self-administration, abuse allegations, grievance handling, environmental concerns, and medication errors.
Findings
The facility was found deficient in multiple areas including failure to assess residents for self-administration of medications, inadequate housekeeping and maintenance, unresolved resident grievances, failure to protect residents from abuse including sexual abuse, improper use of restraints, incomplete care plans, medication errors, lack of trauma-informed care, and failure to conduct background checks and abuse training for volunteers.
Deficiencies (13)
Failure to assess residents for self-administration of medications and develop care plans accordingly.
Failure to provide adequate housekeeping and maintenance services to ensure a clean, comfortable, and homelike environment.
Failure to promptly document and resolve resident grievances.
Failure to protect residents from inappropriate sexual behaviors by another resident.
Failure to ensure residents are free from physical restraints unless medically necessary.
Failure to perform criminal background checks for volunteers and ensure abuse prevention policies are followed.
Failure to update PASRR forms to include mental health diagnoses.
Failure to develop comprehensive care plans addressing overdose, toileting, PTSD, and self-administration of medications.
Failure to properly supervise residents during medication administration; resident self-administering medications without order.
Failure to provide adequate nutritional support and collect biochemical data related to nutritional status.
Failure to provide respiratory care consistent with professional standards; oxygen tubing undated and no physician order for oxygen.
Failure to limit as-needed anti-anxiety medication to 14 days or provide documented rationale for longer use.
Failure to ensure medication administration according to prescribed route; medications given orally instead of via PEG tube.
Report Facts
Residents affected: 1
Residents affected: 3
Residents affected: 1
Residents affected: 3
Residents affected: 2
Residents affected: 3
Residents affected: 4
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee E24 | Licensed Practical Nurse | Named in medication self-administration and supervision deficiencies |
| Employee E19 | Unit Manager | Named in grievance and medication supervision deficiencies |
| Employee E8 | Nursing Aide | Witnessed inappropriate sexual behavior by Resident R44 |
| Employee E10 | Volunteer Pastor | Named in abuse and training deficiencies |
| Employee E11 | Volunteer | Named in abuse and training deficiencies |
| Employee E3 | Social Worker | Named in PASRR update deficiency |
| Employee E2 | Director of Nursing | Named in medication regimen review, abuse training, and care plan deficiencies |
| Employee E1 | Nursing Home Administrator | Named in abuse training deficiency |
| Employee E21 | Registered Nurse | Named in medication supervision and medication administration deficiencies |
| Employee E14 | Certified Nursing Assistant | Named in respiratory care deficiency |
| Employee E15 | Registered Nurse | Named in respiratory care deficiency |
| Employee E26 | Nursing Assistant | Named in toileting care deficiency |
| Employee E32 | Occupational Therapist | Named in nutritional care deficiency |
| Employee E23 | Physiatry | Named in care plan deficiency related to overdose |
| Employee E30 | Nursing Aide | Named in abuse deficiency |
| Employee E31 | Nursing Aide | Named in abuse deficiency |
| Employee E25 | Registered Nurse | Named in abuse deficiency |
Inspection Report
Routine
Deficiencies: 15
Date: Mar 24, 2025
Visit Reason
The inspection was conducted to assess compliance with resident rights, safety, care planning, abuse prevention, medication management, and other regulatory requirements at Ivy Hill Post Acute Nursing & Rehabilitation LLC.
Findings
The facility was found deficient in multiple areas including failure to assess residents for self-administration of medications, inadequate housekeeping and maintenance, unresolved resident grievances, failure to protect residents from abuse including sexual abuse, incomplete care plans, lack of proper supervision, medication errors, and failure to provide trauma-informed care and staff training on abuse prevention.
Deficiencies (15)
Failure to assess residents for self-administration of medications and develop care plans accordingly.
Failure to provide adequate housekeeping and maintenance services to ensure a clean, comfortable, and homelike environment.
Failure to promptly document and resolve resident grievances.
Failure to protect residents from inappropriate sexual behaviors by another resident and failure to properly investigate and document abuse allegations.
Failure to perform criminal background checks for volunteers and provide abuse training to volunteers.
Failure to identify and assess use of physical restraints such as beds against walls and locked wheelchair seatbelts.
Failure to update PASRR forms to include mental health diagnoses for residents.
Failure to develop comprehensive care plans addressing recent overdose, toileting needs, PTSD, and self-administration of medications.
Failure to properly supervise residents during medication administration and allowing resident to self-administer medications without order.
Failure to provide respiratory care consistent with professional standards, including lack of physician order for oxygen and undated oxygen tubing.
Failure to ensure accurate pain assessments and documentation for a resident on pain management.
Failure to provide culturally competent, trauma-informed care accounting for resident's past trauma and preferences.
Failure to ensure medication regimens were followed timely including laboratory monitoring and pharmacist recommendations.
Failure to ensure residents were free from significant medication errors related to prescribed route of administration.
Failure to provide abuse, neglect, and exploitation training for volunteer staff.
Report Facts
Residents affected: 1
Residents affected: 3
Residents affected: 1
Residents affected: 3
Residents affected: 2
Residents affected: 2
Residents affected: 3
Residents affected: 4
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Volunteers affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee E24 | Licensed Practical Nurse | Reported Resident R94 requested to self administer medications; verified no care plan developed |
| Employee E19 | Unit Manager | Confirmed no locked drawer for Resident R37; confirmed medication storage in Resident R57's bedside table |
| Employee E8 | Nursing Aide | Witnessed Resident R44 removing Resident R63's underwear and reported abuse |
| Employee E10 | Volunteer Pastor | Reported witnessing Resident R44 touching Resident R82 inappropriately; no abuse training provided |
| Employee E3 | Social Worker Director | Confirmed no education on clothing inventory process; acknowledged broken inventory process |
| Employee E1 | Nursing Home Administrator | Unaware of reports of sexual abuse by Resident R44; confirmed no background checks or abuse training for volunteers |
| Employee E2 | Director of Nursing | Unaware of reports of sexual abuse by Resident R44; confirmed no background checks or abuse training for volunteers; confirmed medication regimen review deficiencies |
| Employee E21 | Licensed Nurse | Observed administering medications orally to Resident R116 despite orders for peg-tube administration |
| Employee E22 | Licensed Nurse | Reported pain assessments not completed for Resident R30 |
Inspection Report
Routine
Deficiencies: 11
Date: Jun 13, 2024
Visit Reason
The inspection was conducted as a routine regulatory oversight visit to assess compliance with healthcare facility regulations and standards.
Findings
The facility was found deficient in multiple areas including care plan accuracy, communication needs assessment, adherence to physician orders, vision and hearing services, physical therapy provision, fluid restriction monitoring, behavioral health services, medication storage and labeling, dental services, infection control practices, and maintenance of dietary equipment.
Deficiencies (11)
Failed to review and revise comprehensive person-centered plan of care in a timely manner for one resident (R384).
Failed to assess communication needs and provide appropriate treatment and services to maintain ability to speak and understand preferred language for one resident (R10).
Failed to ensure physician's order related to tube feeding was followed for one resident (R14).
Failed to ensure proper treatment and assistive devices to maintain vision for one resident (R10).
Failed to provide appropriate care to maintain/improve range of motion and mobility for one resident (R14).
Failed to monitor labs for one resident on fluid restrictions (R75).
Failed to provide necessary behavioral health care and services for one resident (R82).
Failed to ensure all drugs and biologicals are stored and labeled in accordance with professional standards in two medication rooms.
Failed to provide routine dental services from an outside resource to meet dental needs for one resident (R36).
Failed to ensure proper infection control practices related to tube feeding and medication administration for residents (R14 and R79).
Failed to maintain all mechanical dietary equipment in safe operating condition.
Report Facts
Residents reviewed: 28
Fluid restriction: 1200
Tube feeding volume: 1422
Tube feeding frequency: 6
Weight loss: 10.8
Dish machine sanitizer concentration: 50
Benzyl ammonium chloride sanitizer concentration: 150
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee E6 | Licensed Nurse | Interviewed regarding Resident R10's communication and vision care deficiencies |
| Employee E9 | Speech/Language Pathologist | Confirmed lack of communication assessment for Resident R10 |
| Employee E13 | Licensed Nurse | Observed administering tube feeding and medication storage issues |
| Employee E18 | Dietician | Interviewed regarding feeding orders and nutritional care for Resident R14 |
| Employee E17 | Physical Therapist | Interviewed regarding lack of restorative physical therapy for Resident R14 |
| Employee E19 | Business Office Manager | Interviewed regarding Resident R14's payor source and custodial care status |
| Employee E12 | Nurse Practitioner | Documented behavioral health notes for Resident R82 |
| Employee E11 | Social Worker | Documented psychotherapy notes and behavioral health concerns for Resident R82 |
| Employee E4 | Unit Manager | Interviewed regarding behavioral health services for Resident R82 |
| Employee E7 | Nursing Assistant | Interviewed regarding Resident R36's dental care needs |
| Employee E2 | Director of Nursing | Confirmed dental services delay and behavioral health interview |
| Employee E14 | Unit Manager | Confirmed medication storage labeling deficiencies |
| Employee E15 | Licensed Nurse | Observed medication administration infection control deficiencies |
| Employee E3 | Director of Dietary Services | Confirmed dietary equipment malfunction |
| Employee E5 | Dietary Aide | Confirmed dietary equipment malfunction |
Inspection Report
Deficiencies: 1
Date: Jun 13, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with dental service requirements, specifically to assess whether routine dental services were provided to residents as required.
Findings
The facility failed to provide routine dental services from an outside resource to meet the dental needs of one of three residents reviewed (Resident R36). Despite evaluations indicating the need for dental extractions and dentures, the required dental procedures had not been completed as of the inspection date.
Deficiencies (1)
Failure to provide routine dental services from an outside resource to meet the dental needs of Resident R36, including failure to complete required teeth extractions and denture fittings.
Report Facts
Weight loss percentage: 10.8
Number of teeth needing extraction: 4
Resident height: 69
Resident weight: 116
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee E7 | Nursing Assistant | Interviewed regarding Resident R36's care and substitute food provision |
| Employee E2 | Director of Nursing | Interviewed and confirmed that teeth extractions had not been completed and no scheduled dates were documented |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Nov 1, 2023
Visit Reason
The inspection was conducted due to complaints regarding the facility's failure to properly manage residents' personal funds, provide final accounting of funds within 30 days of transfer, and ensure proper referral and transfer processes for residents.
Complaint Details
The complaint investigation found substantiated issues related to failure in managing resident funds and transfer processes, affecting residents R2 and CR1.
Findings
The facility failed to provide quarterly statements of residents' personal funds to residents or their representatives, delayed reimbursement of resident funds after discharge, and did not initiate proper transfer referrals in a timely manner. These deficiencies affected a few residents and were associated with minimal harm or potential for actual harm.
Deficiencies (3)
Failed to provide a resident fund quarterly statement for one of two residents reviewed for personal funds (Resident R2).
Failed to provide a final accounting of funds within 30 days of transfer for one of two residents (Resident CR1).
Did not ensure proper referral was initiated to transfer resident to another facility for one of two residents reviewed (Resident R2).
Report Facts
Resident pension payment: 2383.56
Resident Social Security payment: 1398
Facility charge for 4 days stay: 1978
Reimbursement amount: 1758.56
Reimbursement delay: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee E7 | Business Office Manager | Interviewed regarding responsibility for quarterly statements and billing |
| Employee E1 | Nursing Home Administrator | Interviewed regarding residents receiving funds and lack of proof of mailing quarterly statements |
| Employee E4 | Social Worker Director | Interviewed about transfer referral delays for Resident R2 |
| Director of Nursing | Confirmed no action was taken to initiate transfer process until October 18, 2023 |
Inspection Report
Complaint Investigation
Deficiencies: 12
Date: Aug 17, 2023
Visit Reason
The inspection was conducted based on complaints and concerns regarding resident rights violations, inadequate discharge notices, unsafe and unclean environment, grievance process failures, incomplete PASRR assessments, deficient care plans, lack of nurse aide performance reviews, mental health service deficiencies, and food service safety issues.
Complaint Details
The visit was complaint-related, triggered by multiple allegations including resident rights violations, inadequate discharge notices, unsafe environment, grievance process failures, incomplete PASRR assessments, deficient care plans, lack of nurse aide performance reviews, mental health service deficiencies, and food service safety issues. Substantiation status is not explicitly stated.
Findings
The facility was found deficient in multiple areas including failure to provide written notice for room changes, untimely discharge notices, unsafe and unclean environment with cigarette smoke and flies, lack of grievance forms and grievance follow-up, incomplete PASRR evaluations, inadequate and untimely care plans for residents' dental, diabetes, hospice, and mental health needs, failure to conduct nurse aide performance reviews, failure to provide mental health services, and food service sanitation and garbage disposal issues.
Deficiencies (12)
Failed to provide written notice including reason for room changes to residents prior to moving them.
Failed to ensure discharge notices were completed timely and in completion for Medicare Part A covered services.
Did not maintain a safe, clean, comfortable, homelike environment; cigarette smoke odor and wet floors noted.
Failed to ensure grievance/concern forms were available to residents, family, or visitors in all nursing units.
PASRR screening not appropriately completed; no Level II PASRR evaluation for resident with serious mental illness.
Failed to develop and implement comprehensive person-centered care plans related to dental, diabetes, hospice, and mental health needs.
Failed to review and revise comprehensive person-centered care plan in a timely manner.
Failed to complete performance reviews for 17 of 17 nurse aide staff.
Failed to provide mental health services to a resident with a mental disorder.
Did not ensure food was stored, prepared, distributed and served in accordance with professional standards.
Did not ensure garbage and refuse was disposed of properly.
Facility was not effectively managed as it submitted inaccurate performance appraisal data during a Federally mandated survey.
Report Facts
Residents reviewed for room change notice deficiency: 32
Residents reviewed for discharge notice deficiency: 3
Nurse aide staff employed: 24
Nurse aide staff without performance reviews: 17
Elevated blood sugar readings for Resident R4: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee E2 | Director of Nursing | Confirmed lack of documentation for room changes, care plan deficiencies, and inability to explain nurse aide appraisal inaccuracies. |
| Employee E6 | Director of Social Services | Confirmed no Level II PASRR evaluation for Resident R21 and no grievance completed for Resident R16. |
| Employee E7 | Food Service Director | Confirmed food service sanitation and garbage disposal deficiencies. |
| Employee E11 | Human Resources | Confirmed nurse aide Employee E12 was hired after performance appraisal date and was not involved in appraisal process. |
| Employee E12 | Nurse Aide | Had a performance appraisal dated before hire date, with signature discrepancies. |
| Employee E13 | Medical Director | Confirmed no blood sugar protocols in Resident R4's clinical record. |
Inspection Report
Routine
Deficiencies: 2
Date: Aug 17, 2023
Visit Reason
The inspection was conducted to assess compliance with residents' rights regarding room changes and to evaluate the safety, cleanliness, and comfort of the facility environment.
Findings
The facility failed to provide written notice including reasons prior to moving residents to different rooms for four residents reviewed. Additionally, unsafe and unsanitary conditions were observed, including cigarette smoke odors near resident areas, wet floors from leaking air conditioning units, presence of houseflies, and a non-draining bathroom sink.
Deficiencies (2)
Failure to provide written notice including reason for room changes prior to moving residents (Residents R86, R36, R16, and R4).
Facility did not maintain a safe, clean, comfortable, homelike environment including cigarette smoke odor near resident lounge, wet floors from leaking air conditioning units, presence of houseflies, and a non-draining bathroom sink.
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Jul 27, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments and care, specifically focusing on the completion of comprehensive MDS assessments after significant changes in resident condition and adherence to physician orders for weekly weight monitoring.
Findings
The facility failed to complete a comprehensive MDS assessment after significant changes in activities of daily living were identified for one resident. Additionally, the facility did not follow physician orders for weekly weight monitoring for the same resident, resulting in a 14% weight loss without timely documentation or intervention.
Deficiencies (2)
Failure to complete a comprehensive MDS assessment after significant change in condition for one resident.
Failure to ensure physician's orders were followed related to weekly weight monitoring for one resident.
Report Facts
Weight loss percentage: 14
Dates of MDS assessments: January 23, 2023; April 10, 2023; June 5, 2023
Weight measurements: 249.6 lbs on admission, 212.6 lbs on April 19, 2023, 213.0 lbs on April 20, 2023, 214.2 lbs on June 6, 2023, 216.4 lbs on July 5, 2023, 214.5 lbs on July 12, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee E4 | Registered Nurse Assessment Coordinator | Interviewed confirming requirement for significant change assessment MDS completion. |
| Employee E3 | Dietician | Interviewed regarding employment start date and previous dietician status. |
| Employee E2 | Director of Nursing | Interviewed confirming lack of weight records for resident R1 between January 16, 2023, and April 19, 2023. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Apr 25, 2023
Visit Reason
The inspection was conducted due to complaints regarding the facility's failure to provide timely laboratory testing and appropriate care for residents with urinary catheters experiencing bleeding and other complications.
Complaint Details
The complaint investigation revealed that Resident R1 experienced bleeding from a Foley catheter starting April 8, 2023, with delayed urine analysis and culture testing. The resident was not treated for UTI during this time and was sent to the hospital on April 13, 2023, where she required two units of blood transfusion. Resident R1's daughter expressed frustration over the delay. Resident R3 also experienced delayed lab testing with results not available until three days after sample collection.
Findings
The facility failed to obtain timely urinary studies and laboratory tests for residents with urinary catheters experiencing bleeding and hematuria, resulting in actual harm to Resident R1 who required hospitalization and blood transfusion. Delays in lab sample processing and communication failures were noted. Similar delays were found for Resident R3's lab testing.
Deficiencies (2)
Failure to obtain a urinary study in a timely manner for a resident with an indwelling urinary catheter experiencing bleeding, resulting in actual harm.
Failure to provide timely, quality laboratory services/tests to meet the needs of residents, including delayed lab sample pickups and processing.
Report Facts
Units of blood transfused: 2
Hemoglobin level: 5.2
Hematocrit level: 16.6
Lab sample collection delay: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee E9 | Licensed nurse, Unit Manager | Interviewed regarding awareness of bleeding on April 8, 2023, and lab sample collection issues. |
| Employee E11 | Licensed nurse | Documented nursing notes on April 8 and 9, 2023, regarding Resident R1's bleeding and condition. |
| Employee E12 | Licensed nurse | Noted urine specimen collection on April 10, 2023. |
| Employee E13 | Attending physician | Provided order for urine analysis and culture testing for Resident R1. |
| Director of Nursing | Director of Nursing (DON) | Confirmed timeline and delays related to Resident R1 and Resident R3 lab testing and condition changes. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Mar 1, 2023
Visit Reason
The inspection was conducted following a concern related to Resident R1 being transported to a medical appointment without an escort, which was a complaint investigation triggered by this incident.
Complaint Details
The complaint was substantiated regarding Resident R1 being transported alone to a neurology appointment without an escort, which led to the appointment being cancelled. The facility investigated and confirmed the issue, educated staff, and rescheduled the appointment with an escort.
Findings
The facility failed to ensure adequate supervision for Resident R1 during a medical appointment, resulting in the appointment being cancelled due to no escort present. The facility educated staff on appointment policies and rescheduled the appointment with an escort. Additionally, the facility was found to have environmental deficiencies including rusted wall light coverings, stained ceiling panels, and unsanitary bathroom conditions on the second floor nursing unit.
Deficiencies (2)
Failed to ensure residents were provided with adequate supervision in accompanying for medical appointments (Resident R1).
Failed to maintain a safe, sanitary, and comfortable environment for residents in the facility (Second Floor Nursing Unit).
Report Facts
Residents' records reviewed: 5
Residents affected: 1
Nursing Units Observed: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee E11 | Charge Nurse | Interviewed regarding Resident R1's transport to neurology appointment |
| Employee E3 | Charge Nurse of second floor | Confirmed environmental deficiencies during observation tour |
| Employee E2 | Assistant Director of Nursing | Interviewed and confirmed environmental deficiencies and investigated Resident R1's transport incident |
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